Chapter 2: Literature Review
2.3. Risk-taking behaviour: definition and a brief background
2.3.1. Adolescent’s common risk-taking behaviours
2.3.1.1. Sexual-risk behaviour
In most cases, sexual-risk behaviour has been solely defined by (or limited to) one or two risk indicators which are usually accounted for by the number of sex partners or the frequency of sexual intercourse (Kalichman et. al, 2006). However, this study adopts a multi-factorial cause that defines sexual risk behaviour by examining among other factors, the number of sex partners, the frequency of sexual intercourse, the quality or nature of the relationship of sex partners, the use of contraceptives or condom use, and the effect substances have on sexual-risk (Gouws et al., 2010; Kalichman et al., 2006; Morojele et al., 2006; Timmermans et al., 2008; Wild et al., 2004).
Adolescents’ sexual activity internationally, according to Flisher et al. (1993e), is marked by early onset, multiple partners, and a low incidence of contraceptive usage. Thus, high rates of sexually transmitted infections and unwanted pregnancy are common among adolescents and are on the rise the world over (Flisher et al., 1993e; Timmermans et al., 2008). Sub-saharan Africa (including South Africa, Zambia, Tanzania, among other countries) for instance, is marked by carrying the greatest burden of HIV/AIDS, with over 60% of 41 million people living with HIV/AIDS in the world are living in Sub-saharan Africa (Kalichman et al., 2006; UNAIDS, 2007).
South Africa was declared the largest country with the most HIV infection rates the world over (UNAIDS, 2007). As a result, hospitals were experiencing difficulties in managing and dealing with escalated numbers of patients with HIV-related diseases (Gouws et al., 2010). South African adolescent’s sexual risk behaviour is also a matter of grave concern because it is associated with high prevalence rates of HIV/AIDS (Wild et al., 2004). Thus, indicating an increasing trend of sexual risk behaviour among adolescents in South Africa. In addition, high risk-sexual behaviour among adolescents has been linked to their increasing susceptibility to HIV infection, thus high prevalent rates of HIV/AIDS amongst adolescents. That is, 34% of all new HIV infections in the year 2005, according to Gouws et al. (2010), were reported to be among the age group of 15 – 24 year olds. Buthelezi, Mitchell, Moletsane, De Lange, Taylor, and Stuart (2007) also revealed that youths between the ages of 15 and 24 are at higher risks in terms of HIV prevalence and incidence. Although many adolescents are at a higher sexual risk, many do not know their HIV status (MacPhaila, Pettifor, Moyo & Rees, 2009).
Regular HIV testing and the knowledge of one’s HIV status has become an integral part in the treatment and preventative measures of HIV/AIDS (Buthelezi et al., 2007; MacPhaila et al., 2009). According to Makiwane and Mokomane (2010), HIV testing is a significant strategy that is necessary for behaviour change, and it influences condom use or safe sex practice in the fight against HIV/AIDS. However, they also revealed through their study that a less number (less than one-third) of adolescents have been tested for HIV in South Africa. Of the few who have reported being tested, more females than males were the majority who ever reported being tested for HIV (Makiwane & Mokomane, 2010), suggesting high sexual-risk behaviour tendencies among males by being ignorant to HIV testing. Overall, the need for more voluntary counselling and HIV testing is still far from being realized or met (MacPhaila et al., 2009; Makiwane &
Mokomane, 2010).
Sexual-risk behaviour, although common in both sexes, it is characterized differently by each gender. Although females are not exempt from carrying out sexual-risk behaviour, a qualitative study by Morojele et al. (2006) found that sexual-risk was more common among males than females. The study also explained reasons for sexual-risk behaviour among both sexes.
Females on the one hand, reported unsafe sex or sexual-risk because of their desire to please their sexual partner and their inability to resist sexual advances from males out of fear of rejection or being beaten. However, males on the other hand cited the success of attaining a status (that is, streetwise, powerful, boss), belief that condoms dampens the pleasure of sexual intercourse, and the perceived thrill of having multiple sex partners as impediments to their safe sex practices, hence their high reported sexual-risk behaviour.
Although, males have greater influence than females on sexual-risk behaviour, females still remain high on sexual-risk behaviour at face value (Buthelezi et al., 2007; Kalichman et al., 2006; MacPhaila et al., 2009; Timmermans et al., 2008). For instance, of the new reported 57 1000 HIV infections in South Africa in the year 2005, about 90% of those infected were women within the age group of 15 - 24 years, suggesting that sexual-risk behaviour is more common in females than males (Gouws et al., 2010).
Flisher et al. (1993e) contends the former by indicating that sexual-risk behaviour is more common in males than females, and this trend is consistent with international findings.
Flisher and his colleagues, further argued that more males than females display more tendencies of sexual-risk, because males are more likely to commence sexual activity at an early age, to have engaged in sex with multiple-partners or a partner they hardly knew or knew for a short period, to have a greater number of sexual partners, to have sexual encounters more frequently, and are likely not to use condoms.
Most South African youths know and understand very well the importance of condom use and that it prevents HIV, sexually transmitted infections, and unwanted pregnancy (Hendriksen, Pettifor, Lee, Coates, & Rees, 2007). Nonetheless, inconsistent condom use is still prevalent among adolescents, despite their knowledge that it remains by far the most effective protection against HIV and other sexually transmitted infections, especially for those who are sexually active. A study by Hendriksen et al. (2007) revealed that 87% of South African youth reported that condoms are readily available and easily obtainable because they are provided by the government free of charge in the public sector and are placed in accessible venues like clinics, and schools or universities, and yet most still engage in unsafe sexual intercourse.
Consistent condom use or safe sex practice can be enhanced by one or two factors. Some of these factors amongst others are described by Hendriksen et al. (2007) as effective communication between partners, coercion linked to sexual power dynamics, sexual power dynamics, and sexual gender. For instance, open and efficient communication among partners promotes safe sex practice as compared to a couple with communication difficulties, whereby the socio-economic dominant partner makes most of the crucial decision alone. For example, young partners or couples who were more likely to have used a condom during their most recent sexual encounter, were probably young partners who openly talked about condom use than those who never talked about condom use initially (Hendriksen et al., 2007).
Both sexes display tendencies to refrain from condom use, although the motive behind this risky behaviour is unique to each gender. On the one hand, females intentionally refrain from condom use in order to conceive, please their sexual partner out of fear, and belief that they have less decision making powers. On the other hand, males deliberately refrain from condom use in order to avoid reduction of the sexual pleasure during intercourse, peer pressure and the thrill of the behaviour thereof (Makiwane & Mokomane, 2010; Morojele et al., 2006).
Inconsistent condom use or condom use is influenced by various factors, which affect condom use either negatively or positively. According to Hendriksen et al. (2007), factors such as alcohol or substance abuse, self-efficacy, risk perception, knowledge of one’s HIV status, and early age of sexual engagement, negatively or positively influence condom use. For example, adolescents who adopt a low sexual risk perception are less likely to use a condom (or use it inconsistently), whilst those who uphold a high risk sexual perception are more likely to use a condom regularly or consistently, thus safe sex practice. About 31% of young people, according to Makiwane and Mokomane (2010), reported that they never used a condom when they had sex with their recent partners in the past twelve months.
Most adolescents are engaged in sexual intercourse with more than one partner.
Makiwane and Mokomane (2010) confirm through their study, that multiple sexual partners are a common practice among young people in South Africa. They also revealed through qualitative studies that concurrent sexual partnerships are normative in South Africa.
This explains the current escalated hype of sexual-risk behaviour among adolescent and the country as a whole. More details and traits about multiple sexual partners have been intertwined throughout the discussion in this sub-section.
Early sexual debut is a characteristic of sexual-risk behaviour, regarded as a risk factor (Flisher et al., 1993e; Hendriksen et al., 2007; Morojele et al., 2006). In cognizant to early sexual debut, sexual risk behaviour is thus characterized differently in various racial groups. For example, a study by Makiwane and Mokomane (2010) revealed that more blacks engage in sex earlier than their racial counterparts, whilst Indians were found to be the least racial group that engage in sex earlier. The trend is similar when comparing young people in urban areas and those in rural areas, whereby more urban young people engage in sex earlier than those in rural areas, with those staying in the farms being the least group of young people to delay sexual debut (Makiwane & Mokomane, 2010).
A link between substance use or abuse and sexual-risk behaviour has been rigorously established by many researchers (Gouws et al., 2010; Kalichman et al., 2006; Morojele et al., 2006; Timmermans et al., 2008; Wild et al., 2004), whereby substance use or abuse was identified as a contributing factor that leads to sexual-risk behaviour. For instance, formal and informal alcohol serving places make up to 94% of places where people find or meet their new sexual partners (Kalichman et al., 2006). A study by Timmermans et al. (2008) revealed that the increasing number of teenage pregnancies and sexual transmitted infections are accounted for by alcohol or drug dependence amongst other factors such as psychological disorders, and education failure.
Sexual-risk behaviour is reported by young people to be linked to drug use because they heighten or induces sexual arousal; impairs judgments which cause engagements in irresponsible sexual behaviours; and they are related to commercial sex work (Morojele et al., 2006).
Furthermore, research revealed strong associations among alcohol use within sexual contents, sexual risk behaviour, and sensation seeking (Kalichman et al., 2006). For example, alcohol use is directly linked to unfamiliarity with sex partners and inconsistent condom use in circumstances where sex was preceded by alcohol consumption.
A low self-esteem is negatively related to sexual-risk behaviour. A study by Wild et al.
(2004) confirms that low self-esteem undermines safe sex practice, abstinence, monogamy, and condom use amongst young South Africans. Their findings also suggest that low self-esteem in the family context highly correlates with sexual risk behaviour for both boys and girls. That is, interventions geared towards the improvement of communication between adults and adolescents within the home context could possibly reduce sexual-risk behaviour among adolescents (Wild et al., 2004).
Overall, sexual-risk behaviour has been identified as a major form of risk-taking behaviour amongst adolescents. Sexual-risk behaviour has also been clearly defined, explained and linked to various causes and factors that directly or indirectly lead to such behaviour. The next section will explore the use or abuse of substances as a major form of risk-taking behaviour amongst adolescents by looking at alcohol use, cigarette smoking, dagga smoking, and illicit drug use.
2.3.1.2. Substance abuse